Neighborhood utilizes the Centers for Medicare and Medicaid Services (CMS) current definitions to define First Tier, Downstream, and Related Entities (FDRs):
First Tier Entity: any party that enters into a written arrangement, acceptable to CMS, with an MAO or Part D plan sponsor or applicant to provide administrative services or health care services to a Medicare eligible individual under the MA program or Part D program.
Downstream Entity: Any party that enters into a written arrangement, acceptable to CMS, with persons or entities involved with the Medicare Advantage benefit or Part D benefit, below the level of the arrangement between a Medicare Advantage Organization or applicant or a Part D plan sponsor or applicant and a first tier entity. These written arrangements continue down to the level of the ultimate provider of both health and administrative services.
Related Entity: Any entity that is related to a Medicare Advantage Organization or Part D sponsor by common ownership or control and:
1. Performs some of the Medicare Advantage Organization or Part D plan Sponsor's management functions under contract or delegation;
2. Furnishes services to Medicare enrollees under an oral or written agreement; or
3. Leases real property or sells materials to the Medicare Advantage Organization or Part D plan sponsor at a cost of more than $2,500 during a contract period.
Affiliate is a person, provider or entity who provides care, services or supplies under the Medicaid program, or a person who submit claims for care, services or supplies for or on behalf of another person or provider for which the Medicaid program is or should be reasonably expected by a provider to be a substantial portion of their business operations.